Transcription of Speech Therapy Prior Authorization Request Form 11962 ...
1 Speech Therapy Prior Authorization Request Form 11962 . Please fax to OrthoNet at: 1-844-888-2823. Fax Date: _____# of Pages Faxed: _____. Therapy PROVIDER INFORMATION. Facility or Provider Name Street Address City State ZIP. Telephone Number Fax Number ( ) - ( ) - The above fax number will be used to confirm your address/location if we are unable to contact you using the fax number on file with Healthfirst Healthfirst Provider ID National Provider Identifier (NPI) Provider Tax ID Number Facility NPI Number Individual NPI Number Facility TIN Number Individual TIN Number PATIENT INFORMATION: First Name Last Name Date of Birth / /. Month Day Year Healthfirst Member ID Number Medicaid Member ID Number OR. Request INFORMATION: Is this Request for post-operative Therapy visits? Request for: Yes No Onset (Commencement) of Therapy Services Initial Evaluation Date Extension of Therapy Services Other Procedure: _____ / /.
2 Month Day Year Service Type: Diagnosis Code (ICD-10 Format). Speech Therapy Instructions: 1. Use this form when requesting Prior Authorization of Therapy services for Healthfirst members. 2. Please complete and Fax this Request form along with all supporting clinical documentation to OrthoNet at 1-844-888-2823. (This completed form should be page 1 of the Fax.). 3. Please ensure that this form is a DIRECT COPY from the MASTER. 4. Please PRINT, in black ink, one character per box for ALL requested information and completely fill in each circle for selection where applicable. 5. For assistance in completing this form, please call OrthoNet provider services toll free at 1-844-641-5629. NOTE: The information transmitted is intended only for the person or entity to which it is addressed and may contain CONFIDENTIAL material. If you receive this material/information in error, please contact the sender and delete or destroy the material/information.
3 For Internal Office Use Only Reset A S P. 11962 . Copyright 2018 OrthoNet, LLC. Rev. 8/29/2018.
